NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
A client with an obsessive-compulsive ritual.
Question 1 of 5
The nurse recognizes that the client with an obsessive-compulsive ritual is attempting to
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) inaccurate (2) inaccurate (3) correct-obsessive-compulsive rituals are an attempt to avoid or alleviate increasing levels of anxiety; client is not trying to increase his self-esteem or control others with the ritualistic behaviors; these behaviors do not have a significant impact on others; client does not want to repeat the act but feels compelled to do so (4) ritual is not a method of expressing anxiety, but a strategy to avoid it
Extract:
The nurse observes the student nurse enter wearing a gown, gloves, and a mask.
Question 2 of 5
The nurse determines that the precautions are correct if the student nurse is caring for which of the following clients?
Correct Answer: D
Rationale: Strategy: Determine the precautions required for each disease. (1) requires contact precautions, no mask (2) requires contact precautions, no mask (3) standard precautions (4) correct-droplet precautions used for organisms that can be transmitted by face-to-face contact, door may remain open
Extract:
Question 3 of 5
The nurse is caring for a client with a history of seizures.
Correct Answer: C
Rationale: Turning the client to the side during a seizure maintains an open airway, preventing aspiration and ensuring oxygenation, which is the priority. Restraining limbs risks injury, tongue blades are contraindicated, and medication administration follows airway management.
Extract:
A client after a bronchoscopy.
Question 4 of 5
The nurse would be MOST concerned if which of the following was observed?
Correct Answer: C
Rationale: Strategy: 'MOST concerned' indicates a complication. (1) would cause a complication if client is given fluids before the gag reflex has returned (2) common for a few days after a biopsy (3) correct-client should be assessed for symptoms of respiratory distress from swelling due to the procedure; signs of respiratory distress include tachypnea, tachycardia, respiratory stridor, and retractions (4) expected after this procedure
Extract:
Question 5 of 5
The nurse is caring for a client with a history of anxiety who is receiving lorazepam (Ativan) 0.5 mg PO tid. Which of the following client statements would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Dizziness upon standing suggests orthostatic hypotension, a serious side effect of lorazepam, increasing fall risk and requiring evaluation. Options A, B, and D are less concerning: drowsiness and dry mouth are common, and taking with food is acceptable.